Stress Management

This class is based on portions of The Relaxation and Stress Reduction Workbook and Leader’s Guide by Martha Davis, Elizabeth Robbins Eshelman, and Matthew McKay.  Note:
C	We have ordered for each center a set of three audiotapes (“10 Minutes to Relax”) that accompany the book.  Feel free to loan the tapes to participants as part of this course.  The tapes provide detailed instructions for breathing techniques, guided imagery and visualization, progressive muscle relaxation, meditation, and body scanning.  Look for the tapes in the mail, and let us know if you don’t receive them.
C	We will keep five copies of the workbook and leader’s guide on hand here at the Lifestyle Resource Core to loan to centers as a resource.  Call us to borrow a copy. For example, you may want to add a session to this class on visualization and guided imagery and use the workbook and leader’s guide to develop the session.
C	To order your own copy of the workbook, leader’s guide, or tapes, call Courage to Change at 1-800-935-8838.  

Class Overview

In this class, participants will assess their stress level as it relates to their eating and physical activity and will be taught and practice specific stress management techniques.  The Life Balance Pyramid will be presented with examples of ways to develop and sustain the different areas of the pyramid.

Session 1:  Stress Assessment, Life Balance, and Belly Breathing
Participants will individually assess their stress level as it relates to their eating and physical activity.  The Life Balance Pyramid will be presented, and abdominal (belly) breathing will be introduced and practiced.
Session 2:	More Breathing Exercises and Body Awareness 
Participants will practice some additional breathing exercises and several body awareness exercises. 
Session 3:	Body Relaxation
Participants will be introduced to and practice progressive relaxation.
Session 4:	Mindfulness: Really Doing What You’re Doing
Participants will be introduced to the concept of mindfulness and its benefits for coping with stress.  Participants will also practice mindful eating and walking.

Note:  The class has a strong behavioral focus and participants may bring up challenging personal issues during the sessions, so the leader should be the behavioral consultant at your center or a senior Lifestyle Coach with extensive group experience.

If desired, any of the handouts from this class may also be given to an individual participant during an In-Person visit, provided that the Coach is comfortable presenting the topic and that it is tailored to the needs of the participant.

Note:  All after-core classes should be considered a time for participants to “restart” (resume behavior changes toward their weight loss and physical activity goals).  To accomplish this, all classes should include weigh-ins, encouragement to self-monitor, and collection and review of self-monitoring records.  At Session 1, participants should set goals for fat grams/calories, exercise, and weight loss to achieve during the course.

Session 1:  Stress Assessment,
Life Balance, and Belly Breathing

Objectives:	Participants will individually assess their stress level as it relates to their eating and physical activity.  The Life Balance Pyramid will be presented, and abdominal breathing will be introduced and practiced.
Handouts:		Assess Your Stress, The Life Balance Pyramid brochure from Park Nicollet Health Source (the Lifestyle Resource Core will provide copies for each participant in the class), Breathe Away Your Stress
Before the session:
C	When you advertise the class to participants, emphasize the experiential nature of the sessions (see the purpose given below).  And recommend that participants come dressed comfortably (prepared to practice stretches at some of the sessions).

1.	Explain the purpose of the class:  to help participants: 
C	identify the sources of stress in their lives,
C	learn more about how stress affects their eating and physical activity,
C	think about the bigger picture of “lifestyle balance” and how it relates to stress and stress-related behaviors, and
C	learn several ways to both cope with and prevent stress.  

Emphasize that the overriding purpose of the class is not to add one more thing-I-have-to-do to the participants’ schedules but rather to carve out a little protected time for them during which they reflect on issues related to stress, experience the support of other lifestyle participants, and spend some time learning and practicing relaxation skills that can help them in their efforts to lose weight and maintain it and become more physically active.   

Also point out that some topics to be presented briefly in this class could be full classes in and of themselves.  The purpose of this class is not to attempt to provide participants with some final answers with which they can change their lives but rather to get them thinking about some of these things.  The participants may want to discuss specific issues in more depth and develop related action plans with their Coaches on an individual basis.  

2.	Distribute the notebooks or folders, and review the topics, schedule and locations for each session.  Instruct participants to bring their notebooks/folders with them to every session and keep their handouts and homework in their notebooks.  Also ask participants to wear loose, comfortable clothing, particularly for sessions 1 and 2.

3.	Have participants briefly share their reasons for joining the class.  Ask them to introduce themselves and any guests they have brought to the class and name some of the forms of relaxation and stress management that they may have already learned and/or practiced.  

4.	Make the point that stress is a complex issue.   First of all, stress is not easy to define.  It is not necessarily a situation, because the same situation may be stressful to one person but not to another.  (Perhaps no one would disagree that working in a sweatshop at slave wages is stressful for most people, but is selling peanuts at the ballpark stressful?  It may or may not be, depending on the individual.)  The bottom line may be whether or not you feel stressed, but again, this is complex because different people experience stress in different ways.

Distribute page 1 of the Assess Your Stress worksheet and pencils.  Have participants complete page 1 of the worksheet individually and then ask for volunteers to comment on what they learned.  Emphasize again that one purpose of this class is to help participants break the chain that links stress to unhealthy eating or sedentary behavior.  Remind participants of the concept of action (behavior) chains (described in Session 9 on Problem Solving in the core curriculum).  Distribute page 2 of the worksheet and take one example from the group of a stressful event that led to unhealthy eating or sedentary behavior and work through the behavior chain analysis.  Give an example of a stress management technique that will be taught in this class (such as deep breathing) that could be used as an option for breaking the chain.

5.	Explain that stress management techniques can be used in specific situations to cope with the symptoms of stress (as in the previous example of a behavior chain) and also, when practiced regularly, as a way to prevent stress and stress-related behaviors.  Distribute the Life Balance Pyramid brochure, and introduce it as a guide to creating overall balance in our lives in order to both cope with and prevent stress.  Review the various levels of the pyramid, explaining that each level addresses a different aspect of stress management, and as a whole, the pyramid focuses on the origins of stress and preventing stress as well as how to cope with the symptoms that can result from stress.  

In addition, the pyramid reflects the complex nature of stress and stress management.  When you want to address a particular source of stress in your life, there is no one right answer.  You may need to focus on several areas of the pyramid depending on what options you have open to you.  For example, you may decide that your job is not fulfilling and your dissatisfaction with your job is an important factor in your overeating during your lunch break, but can you quit your job?  Can you change some of the stressful qualities of the job if you can’t quit (such as being more assertive with your boss)?  If you can’t do either, then can you look at the stresses in the rest of your life and at how you react, mentally and physically, to stress in general?  Can you find nonfood ways to cope with the symptoms of feeling stressed and find ways to relieve the negative consequences of the stress?  Explain that today you will briefly review all of the areas on the Life Balance Pyramid and then practice one of the Immediate Coping Skills at the top of the pyramid, the use of deep breathing.  The remaining sessions in the class will touch on various areas of the pyramid as well as introducing specific techniques for stress management.  

6.	Review the Life Balance Pyramid interactively.  Ask the group to comment on any of the areas of the pyramid in general or on any specific items, and build on related points  brought out in the discussion of the worksheet, Assess Your Stress.  Let the participants direct the discussion.  If it lags, provide a few of the following questions to spark interest.  (Only include a few of the questions; you must leave enough time at the end of this session to teach and practice deep breathing.  Also, you may wish to mark some of the questions for use during future sessions, perhaps as an interactive opener to briefly remind participants of the pyramid and review how they may have used it since the previous session.)  During the discussion, be sure to highlight the physical nourishment section of the pyramid as related to the DPP goals of being physically active and losing weight through healthy eating.

Lifelong Foundations
C		One of the lifelong foundations for stress management is to develop a sense of fulfillment from hobbies or work.  What does the word “fulfillment” mean to you?  How do you know when you are fulfilled or not fulfilled?  What would other people notice?  Do you have any ideas of how you might strengthen this foundation in your life?
C	How about making time for meditation and/or prayer (or connecting with a higher power)?  Is spirituality important to you?  Do you make time for spiritual practice and growth, either in a group or alone?  Is it something that you could make time for?
C	Do you observe and appreciate the natural world?  In what way?  For example, while doing any outside physical activity for DPP, do you take advantage of any opportunities to observe and enjoy nature?  Or do you tend to worry about family and work responsibilities and watch the minute hand on your watch while you walk through the park?
C	What does it mean to you to “view life’s challenges as opportunities” (we’ve all heard the phrase, “If life gives you lemons, make lemonade”)?  Do you have any examples of a challenge that became an opportunity for you because of the way you viewed it or handled it?  One way to think about this is to ask yourself, when faced with a stressful situation, “What can I learn from this?”  Instead of getting swept away by an automatic reaction to a stressful situation, can you step back and look for a creative response?  What does it take to approach challenges in this way?  
C	Another lifelong foundation for stress management is reflecting on your personal values, goals, and choices.  One way to think about this is to ask yourself, “If given the chance, would I do some things differently in my life?  If so, what would I do differently?  Are there any small changes in this direction that I could begin making now?”  (Bring out the point that one change might be cultivating a deeper acceptance of the way things are.)

Emotional Well-Being
C	Do you tend to think optimistically?  Have any of you changed from a tendency to be pessimistic to being more optimistic?  (If appropriate, refer to some of the suggestions in the core curriculum session on talking back to negative thoughts.)
C	What do you do to nurture a positive self-image?  
C	Are you able to express feelings in honest, fair, and direct ways?  In what ways does this help keep life in balance?
C	Do any of you write in a journal?  Write letters?  In what ways does writing help keep life in balance?

Social Connection
C		One of the social connections for stress management is to volunteer time to a worthy cause.  Do any of you volunteer?  What is that experience like for you?  What keeps you involved?  Have any of you volunteered before and then stopped doing so?  What got in the way?  Do you have any ideas of how you might strengthen this connection in your life?	
C	How about doing kind deeds for others? In what way do you think this reduces stress and helps to keep our lives in balance?
C	Another social connection on the pyramid is to spend time with family, friends, and pets.  Also listed is caring for children, elderly, and pets.  Some of us would say that family life, especially providing care, often adds stress instead of reducing it.  What do you think?  When is family life and providing care a source of balance?  When is it a source of stress?  What makes the difference? 

Pleasurable Joys
C	Which of the pleasurable joys do you practice regularly?  (If you are comfortable doing so, mention that an important source of pleasurable joy for many of us that is not explicitly listed on the pyramid is romance and sex, which could be thought of as part of the item, “Give and get hugs.” Although this course is not the place for  addressing sexual frustration, there are numerous books, courses and counseling services available to help participants in this area.)  How do pleasurable joys help keep your life in balance?  Do you tend to neglect this area of the pyramid?  How might you include more pleasurable joys in your day-to-day life?  Have you ever experienced eating healthy foods and being physically active as pleasurable joys?

Physical Nourishment
C	The physical nourishment section of the pyramid includes healthy eating, physical activity, and rest, two of which relate directly to the DPP lifestyle change goals.  How do building these in every day help keep your life in balance?  
	  
7.	Demonstrate abdominal breathing.   Remind participants that at every session you will practice a different way to relax.  Today the practice is abdominal or “belly” breathing.   Begin by briefly making the point that proper breathing is a profoundly effective way to relieve stress.  Ask participants why this might be so.  Record their answers on a chalkboard or flipchart if available, and add the following points if not brought out by the group:  
C	Breathing provides life-giving oxygen to all parts of our body and gets rid of carbon dioxide, a toxic waste product.  Poor breathing habits diminish the flow of these gases, which can contribute to anxiety, panic attacks, depression, muscle tension, headaches, and fatigue.
C	Shallow, fast breathing often accompanies anxious and scattered thoughts.  One way to calm and focus our thoughts is to breathe more deeply and slowly. 
C	Proper breathing is simple and convenient.  It requires no equipment and can be done anywhere and anytime without anyone else noticing.  

Ask participants to keep in mind that although proper breathing is simple to learn, most of us have a lifetime of experience with incorrect breathing.  So at first correct breathing will feel awkward and unnatural.  However, with patience and regular practice over an extended period (several months), proper breathing can become automatic and the cumulative relaxing effect can be great. 

Next, demonstrate the belly (abdominal) breathing exercise.  Exaggerate the movement of the belly or rest a book on your abdomen so the movement is easy for the group to see.  
8.	Summarize the main points from this session.  Assign home activity:
C	Keep a stress awareness diary (use your Keeping Track books or another self-monitoring record).  Make a note of the time that a stressful event occurs and the time you notice a physical or emotional symptom or behavior that might be related to the stress, including unhealthy eating or being sedentary.  For example, “10:00 Customer on the phone was rude and angry.  10:15 Stomach tightness, anger.  10:20 Went out for pastry during coffee break.”

C	Practice belly breathing at least once a day and self-monitor your stress level (not at all, somewhat, or very stressed) before and after the practice.  Take a minute now to plan a specific time during the day to practice and write it on the cover of your Keeping Track booklet.  (Check that participants have done so.)  

C	Use belly breathing as a way to respond when you first experience an urge to overeat (some people post a little sign saying “Breathe” on their refrigerator door or computer screen) or an urge to avoid following through with a plan to exercise (ie., as a way to break the chain between stress and unhealthy eating/sedentary behavior).  In these cases, the breathing can serve several purposes: provide relaxation, break the chain between certain thought patterns and unwanted behaviors, and help you become more aware of those thought patterns and behaviors.

C	As you go through the week, keep in mind our discussion of the Life Balance Pyramid.  (Suggest that participants post the Life Balance Pyramid in a place where they can refer to it regularly.)  Note any items on the pyramid that you practice.  Also notice any items or areas on the pyramid that you tend to neglect.

C	Remember to wear loose, comfortable clothing and bring a blanket or mat to the next session.

Session 2:  More Breathing Exercises and Body Awareness

Objectives:	Participants will practice some additional breathing exercises and several body awareness exercises.  
Handouts: 	Other Breathing Exercises, Body Awareness

Before the session:
C	Remind participants to wear loose, comfortable clothing and bring a blanket or mat (if the body awareness exercises must be practiced on the floor).
C	If possible, provide comfortable chairs for participants to sit in during the body awareness exercises.

1.	Briefly review the main points of the last session.  Ask participants if since the last session they practiced any of the items on the Life Balance Pyramid.  Did they have any insights about sections or items on the Life Balance Pyramid that they tend to neglect? 

Also ask for comments on their experiences while practicing belly breathing and keeping a stress awareness diary.  What kind of situations were stressful and what were their related symptoms and behaviors?  How did they rate their stress before and after the breathing exercise?  Were they able to use belly breathing to break a chain between stress and overeating or sedentary behavior? Answer any questions. 

2.	Explain the purpose of this session: to introduce participants to some additional breathing exercises and several body awareness exercises.

3.	Demonstrate additional breathing exercises.  Point out that many people find it difficult to continue a regular practice of belly breathing because their minds wander.  Variations on the exercise can be used to help focus the mind.  Distribute the Other Breathing Exercises handout.  Demonstrate the exercises and allow time for participants to practice them.  Move around the room as they practice, answer questions, point out your observations, and make suggestions. 

4.	Introduce the body awareness exercises.  Another relaxation technique is body awareness.  Our bodies register stress before our conscious minds do, so by purposely shifting our attention from the busy outside world to our bodies, we can become aware of the stress that may be building up and begin to release it.  Today we’ll practice a couple of body awareness exercises, including the body scan that we used briefly in the last session.
Review the body awareness exercises on the handout one at a time, having the participants practice them on a mat on the floor or in comfortable chairs.  As participants practice, move around the room.  Ask for questions and comments.  Encourage participants to take their time and be patient if their attention wanders.  

5.	Summarize the main points of the session.  Assign home activity:
C	Continue to self-monitor your stress and related symptoms and behaviors in your Keeping Track booklets or other self-monitoring records.  (Review the specific instructions given as homework for the last session.)
C	Practice the additional breathing exercises and body awareness exercises during the coming week and self-monitor your stress (not at all, somewhat, or very stressed) before and after the exercises.  Have participants take a few minutes to plan specifically when they will practice, and ask them to write the times on the cover of their Keeping Track booklets.  (Check that participants have done so.)   
C	Use breathing and body awareness as a way to respond when you first experience an urge to overeat or to avoid following through on a plan to exercise (ie., to break a chain between stress and unhealthy eating/sedentary behavior.).     
C	As you go through the week, keep in mind our discussion of the Life Balance Pyramid.  (Again suggest that participants post the Life Balance Pyramid in a place where they can refer to it regularly, if they haven’t done so already.)  Note any items on the pyramid that you practice.  Also notice any items or areas on the pyramid that you tend to neglect.

Session 3: Body Relaxation

Objectives:	Participants will practice progressive body relaxation.

Handouts: 	Body Relaxation, copies of an audiotape with instructions for progressive relaxation for participants to take home and use when practicing (e.g., one of the tapes from the Relaxation and Stress Reduction Workbook)

Before the session:
C	Remind participants to wear loose, comfortable clothing and bring a blanket or mat (if the progressive relaxation exercises must be practiced on the floor).
C	If possible, comfortable chairs for participants to sit in during the progressive relaxation exercises

1.	Briefly review the main points of the last session.  Ask participants if since the last session they practiced any of the items on the Life Balance Pyramid.  Did they have any insights about sections or items on the Life Balance Pyramid that they tend to neglect? 
Also ask for comments on their experiences while practicing the additional breathing and body awareness exercises and keeping a stress awareness diary.  What kind of situations were stressful and what were their related symptoms and behaviors?  How did they rate their stress before and after they practiced the breathing and body awareness exercises? Were they able to use breathing/body awareness to break a chain between stress and overeating or sedentary behavior? Answer any questions. 

2.	Explain the purpose of this session: to introduce participants to progressive body relaxation.  

3.	Introduce body relaxation.  Explain that body or “progressive” relaxation was first introduced in 1929 by a Chicago physician.  It is a simple technique of tensing and then relaxing muscles in four major muscle groups, starting with the hands and arms; moving to the head, face, and shoulders; then to the chest, stomach, and lower back; and finally to the thighs, buttocks, calves, and feet.  Body relaxation allows you to discover which muscles are tense and to distinguish between the sensation of tension, which may be so chronic that it goes unnoticed, and deep relaxation.  The technique has been shown to lower pulse rate, blood pressure, and respiration rates.  It has been used successfully in the treatment of muscular tension, anxiety, insomnia, depression, fatigue, irritable bowel syndrome, muscle spasms, neck and back pain, high blood pressure, mild phobias, and stuttering.
Encourage participants to take what they learn in the class today and practice it twice a day at home.  Explain that at first, the technique may be a little difficult and take about fifteen to twenty minutes, but with a week or so of practice, it will be possible to relax your whole body in just a few moments.  Once you have mastered the technique, a shortened form can be used which tenses and relaxes many muscles at one time so that deep relaxation can be reached in a very brief period of time.  In this class, we will practice the longer form, but first I will demonstrate the shortened form as a way of showing you certain parts of the technique.  

4.	Give participants the handout, Body Relaxation.  Review the handout, including the instructions and cautions.   (Make the additional point that excessive tightening of the back or neck could cause muscle or spinal damage.  However, mild tingling, jerking, needlelike sensations, and warmth are all normal sensations during progressive relaxation.)  Then demonstrate each of the steps in the shortened form as a way of illustrating how to tense and relax the muscles.  Explain that sometimes people let their arms or legs relax in a slow, controlled way (demonstrate this), which actually requires sustained muscle tension, rather than letting them fall suddenly limp, which is a sign of tension release (demonstrate this).  (It may be helpful to make this point by using the metaphor of turning off a light switch.)  Another problem is either tensing too little to feel the benefit of releasing (demonstrate this) or tensing so much that you are straining (demonstrate this).

Then ask participants to lie down on a rug or blanket or sit in a chair (whichever is most comfortable for them) in a comfortable position with their eyes closed.  Explain that it is important to be physically comfortable but not so much so that you are likely to fall asleep, which is a problem with lying down for many people, particularly in a bed.  For practice at home, a comfortable recliner that supports the arms, legs, and head may be ideal.  

5.	Read the script below aloud, or play an audiotape of yourself reading the script, or play another instructional tape on progressive relaxation (a 22-minute audiotape, Progressive Relaxation, is available from New Harbinger Publications; to order, call the 800 number on page 1).  
C	If you use the script below, allow participants time to experience the sensations of tensing and relaxing one muscle or muscle group before going on to the next one (again, allow about 5 to 10 seconds for tensing each muscle and 15 to 30 seconds for relaxing).  
C	One advantage of making a tape of yourself reading the script is that you can listen to it while practicing the exercise yourself before class, which will help you check your timing and give you a chance to make any modifications before the class.  
C	Another advantage of using a tape, rather than reading the script aloud during the session, is that it will be more convenient for you to walk around the room and point out any individual problems you observe. 
C	We strongly recommend that you give participants copies of the tape, either the New Harbinger Publications tape or your own, for use when practicing at home.  

Script:
“Get in a position that is comfortable for you.  Good.  First, clench your left fist.  Clench it tighter and tighter and keep it clenched.  Notice the tension in your fingers, hand, and lower arm.  Now relax.  When you relax, do so all at once, like turning off a light switch. Feel the looseness in your fingers, hand, and lower arm.  Notice the difference between the looseness and the tension.  Now clench the fist again...then relax it suddenly.  Feel the difference.  Next, clench your right fist.  Tighter and tighter and keep it clenched.  Notice the tension.  Now relax.  Feel the looseness.  Notice the difference between the looseness and the tension.  Again, clench your right fist.  Relax.  Now tense both fists at once.  Relax both fists.  Notice the difference.  Tense both fists again.  Relax.  Let go more and more.

Now bend your elbows and tense your upper arms, your biceps.  Tighter and tighter, as hard as you can.  Notice the tightness.  Now relax and straighten out your arms.  Feel the looseness.  Notice the difference.  Tense your upper arms again.  Hold.  Relax.  Let go more and more.

Move your attention to your head now.  Wrinkle your forehead as tightly as you can.  Let it relax.  Imagine your entire scalp and forehead smoothing out and relaxing.  Now frown again.  Notice the tension in your forehead.  Let it go.  Let your brow become smooth and at complete rest.  Now close your eyes, tighter and tighter.  Notice the tension.  Relax them, letting them stay closed gently.  Tighten them again.  Relax.  Next, clench your jaw.  Notice the tension.  Relax it.  Let your lips be slightly parted.  Notice the looseness in your jaw.  Notice the difference between the tension and the relaxation.  Again, tense your jaw.  Relax.  Now press your tongue against the roof of your mouth.  Feel the tension in the back of your mouth.  Relax.  Again, press your tongue up.  Relax. Now tightly purse your lips into an “O.”  Relax them.  Again, purse.  Relax.  Take a minute now to notice the looseness in your forehead, scalp, eyes, jaw, tongue, and lips.  

If your head is supported, press it back as far as you can comfortably against the floor or bed.  Notice the tension in your neck.  Now roll your head to the right, feel the tension, then to the left.  Now straighten your head and press your chin against your chest.  Hold it there.  Feel the tension in your throat and the back of your neck.  Now relax and return your head to a comfortable position.  Let the tension dissolve away.  Again, press your head back.  Roll it to the right, to the left, straighten, chin against your chest.  Now relax.  Now hunch your head down between your shoulders and hold your shoulders there.  Feel the tension.  Now drop them.  Feel the relaxation.  Again, hunch your shoulders.  Drop them.  Let the relaxation spread through your neck, throat, and shoulders.  Let the relaxation deepen.

Give your whole body a minute now to relax.  Feel the heaviness in your muscles.  Feel the calmness, the comfort, the rest.  

Now, breathe in and fill your lungs.  Hold your breath, and notice the tension in your chest.  Now breathe out, letting the air hiss out.  Let your chest become loose.  Continue breathing freely and gently.  Notice the tension drain from your body.  Again, breathe in and hold.  Breathe out.  Relax.  Next, tighten your stomach.  Tighter, tighter, hold it.  Notice the tension.  Relax.  Put your hand on your stomach and breathe into your belly, pushing your hand up.  Hold, then relax.  Feel the relaxation as you breathe out.  Again, tighten your stomach.  Relax.  Breathe into your belly, hold.  Relax.  

Now arch your back without straining.  Don’t overdo it.  Keep the rest of your body relaxed.  Turn your attention to your lower back.  Notice any tension there.  Now relax.  Let your lower back muscles relax and smooth out. Again, arch your back without straining.  Relax.  Let go more and more.

Tense the muscles in your buttocks, tighter and tighter.  Hold the tension while you press your heels down as hard as you can until you feel the tension in your thighs.  Now relax all at once.  Feel the difference between the relaxation and the tightness.  Again.  Tighten your buttocks, press your heels down.  Relax.  Now curl your toes downward, tensing your calves (don’t overdo it or your might get a muscle cramp).  Feel the tension.  Relax.  Again, curl your toes down.  Relax.  Now bend your toes toward your face, tensing your shins.  Relax.  Again, bend your toes toward your face.  Relax.

Take a minute now to let the relaxation deepen.  Let the tension throughout your lower body drain away.  Relax your feet, ankles, calves, shins, knees, thighs, and buttocks.  Let the relaxation spread now to your stomach, lower back, and chest.  Let go of the tension Let the relaxation deepen in your shoulders, arms, and hands.  Let go more and more.  Notice the looseness in your neck, jaws, and facial muscles.”  

6.	Reassemble the group and have participants discuss their experience.  Answer any questions.  

7.	Summarize the main points of the session.  Assign home activity:
C	Continue your stress awareness diary.
C	Practice body relaxation twice per day and self-monitor your stress before and after practicing.  Have participants take a few minutes to plan specifically when they will practice, and ask them to write the times on the cover of their Keeping Track booklets.  (Check that participants have done so.)   
C	Use the short form of body relaxation as a way to respond when you first experience an urge to overeat or to not follow through with a plan to exercise (ie., to break the chain between stress and unhealthy eating/sedentary behavior).  
C	As you go through the week, keep in mind our discussion of the Life Balance Pyramid.  (Again suggest that participants post the Life Balance Pyramid in a place where they can refer to it regularly, if they haven’t done so already.)  Note any items on the pyramid that you practice.  Also notice any items or areas on the pyramid that you tend to neglect.

Session 4:  Mindfulness: 
Really Doing What You’re Doing

Objectives:	Participants will be introduced to the concept of mindfulness and its benefits for coping with stress.  Participants will also practice mindful eating and walking.
Materials needed:
C	Name tags
C	Box of raisins for the mindful eating exercise.  (The exercise may be done with any food,  such as a sandwich, sliced apples or pears, or seeded sections of tangerine.  Raisins are a good choice because they are easy to pack, won’t spoil, and most people like them.  If not using raisins, keep in mind that some other foods may spoil and that some types of sliced fruit, such as apples or pears, will darken in contact with air once they are cut.)
C	Keeping Track booklets
C	Pencils
Note:
C	This session should be held in a room that can be arranged to allow the group to walk in a circle or in lanes.  
C	An excellent resource for Coaches and participants that includes detailed instructions on the practice of mindfulness is Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness by Jon Kabat-Zinn, PhD.  
C	Another resource is Eat More, Weigh Less by Dean Ornish, MD.  Part 1 addresses broader lifestyle balance issues.

1.	Briefly review the main points of the last session.   Ask participants if since the last session they practiced any of the items on the Life Balance Pyramid.  Did they have any insights about sections or items on the Life Balance Pyramid that they tend to neglect?  Also ask for comments on their experiences while practicing the body relaxation.  Were they able to break a chain between stress and eating/sedentary behavior by using body relaxation?  Answer any questions. 

2.	Explain the purpose of this session and define mindfulness.  The purpose of this session is to give participants some exercises for practicing what is called “mindfulness” as a way of coping with the stresses of life.  Most stress comes from thinking about the past or worrying about the future and letting this block out our experience of the here and now, the “present moment.”  Mindfulness can be defined as “paying attention on purpose,” or living in the present moment, really doing what we are doing right now. 
Briefly describe some examples to illustrate that most of us at one time or another in our lives have experienced mindfulness:
C	During play (e.g., playing chess, tennis, dancing), you are so focussed on each moment that you’re not aware of time passing.
C		At a moment of crisis (e.g., your four-year-old runs home crying with a cut on her  elbow), you are vividly aware of all of the details of your surroundings and feel completely alert and focussed.

Ask for additional examples from the group.  Explain that in moments like those described, our minds are typically calm, concentrated, and aware of the immediate sensations of what we are doing.  Ask the group what is different about our minds when we experience stress.  Make the point that under stress, our minds are typically agitated and dispersed or scattered.  This is sometimes called “monkey mind,” when our mind wildly swings from one thought to another like a monkey swinging from branch to branch.  For example, while we are driving to work, we might be worrying about something our spouse said during a recent argument, then thinking about what our boss might say when we get to work, rather than experiencing the actual sensations of driving or even seeing where we are going.  We are on “automatic pilot,” and our mind is somewhere else.  

Clarify that there is nothing “wrong” with thinking about something other than what is happening in the present moment.  At times it is necessary and helpful (for example, planning ahead to schedule an appointment).  But frequently, thinking about something else is not at all helpful.  By practicing mindfulness, we learn that we have a choice.  We can choose the option of consciously focusing our mind on the present moment which is always available to us.

Explain that there is nothing unusual or mystical about mindfulness.  Some people practice mindfulness by sitting regularly in meditation, but this is not necessary.  [Note:  Refer participants who ask for instructions for sitting meditation to Full Catastrophe Living, the resource described in the objectives for this session which includes a good bibliography of additional resources.]  In fact, there are countless moments in our ordinary lives that we can use for practicing mindfulness, such as setting the table, eating, washing the dishes, writing, doing the laundry, taking a shower, brushing our teeth, shaving, getting on a bus, hugging, or sitting on our front steps.

Let’s take doing the dishes as an example.  To do the dishes mindfully, you would be aware of how your body moves when it holds, scrubs, and rinses each plate and glass.  You would also be aware of your breathing and of any thoughts or feelings you experience.  You would note or name the thoughts and feelings briefly (for example, you might say to yourself, “I was having a thought about what I need to do tomorrow morning at work.  Feeling a little anxious.”).  Then you would return your full attention to the immediate sensations of doing the dishes.  

Practicing mindfulness while doing ordinary daily activities has many benefits.  First of all, you might discover that you actually enjoy doing the dishes, and all the other ordinary routines you do every day, that you don’t have to rush through doing these things so you can get on to something more important.  Secondly, your practice will strengthen your ability to be present and aware, so that in moments of depression, anger, or anxiety, you can use the same ability to focus yourself, to be alert and aware and attentive, instead of acting mechanically without full awareness.  After all, the present moment, no matter what it contains, is the only moment we have to learn, to heal, to act, to change.  If our minds are somewhere else, we are shortchanging our life.

3.	Have the group practice mindful eating.  Give each participant in the group three raisins (this can also be done with slices of apple or pear or seeded sections of a tangerine; raisins may be the best option in some situations because they do not spoil or darken on contact with air as do other cut fruit).  Explain, with a little humor, that you are now going to do a group exercise in which you all “really eat these raisins.”  (Expect some nervous laughter throughout this exercise.)   Note that this may seem silly, but even the most simple acts like eating a raisin can illustrate how powerful mindfulness can be.   Lead the group in your own words, using the following script as a guide.

“Hold one of your raisins in your hand.  Take several slow, deep breaths.  Now look at the raisin as if you had never seen one before.  What color is it?  What is its surface like?  What does its texture feel like between your fingers?  What thoughts are you having now about raisins or about food in general?  Are you having any thoughts or feelings about liking or disliking raisins?  Whatever your thoughts or feelings are, simply notice them.  

Be aware of your intention to begin eating.  Move your other hand slowly toward the raisin.  Note the action mentally by saying to yourself, “Reaching ... reaching ... reaching.”  Now pick up the raisin, and say to yourself, “Lifting .... lifting ... lifting.”  The point is to stay aware of each movement of your hand and arm by naming them.

Now move the raisin closer to your mouth and watch your hand as you do so.  Smell the raisin.  What does it smell like?  How are you reacting to the smell?  Is your mouth watering?  If so, notice what it feels like to desire food.

Put the raisin on your tongue.  What does it feel like?  Is your mouth watering?  Now bite into the raisin.  Where is the raisin in your mouth?  Begin chewing slowly.  What are the sensations in your teeth?  Your tongue?  How does your tongue move when you chew?  What part of your tongue is experiencing the taste?  Where is your arm?  Did you notice moving it to where it is now?

When you are ready to swallow, notice the impulse to do so.  Now swallow the raisin.  Try to be aware of how the raisin moves in your esophagus toward your stomach.  Can you feel any sensations in your stomach?  Where is your stomach?  What size is it?  Is it empty, full, or in between?  Imagine that your body is now ‘one raisin heavier’.

Now take as much time as you need to eat the other two raisins with the same degree of mindfulness.”

Ask the group to share their experiences with the exercise.  If not brought out in the discussion, ask the following questions:
C	How did this experience differ from the way you usually eat?
C	Were you “satisfied” eating one raisin?
C	What would it be like if you ate this way most of the time?  Do you think it would affect the amount and/or types of foods you eat?  Your attitude toward eating?  (With mindfulness, healthy eating can become one of the pleasurable joys on the Life Balance Pyramid.)
C	Did you automatically start to eat the other raisins before you were finished with the first one?

4.	Have the group practice mindful walking.  Introduce the next exercise by stating that walking is another ordinary activity that can be used for practicing mindfulness.  Usually we walk for a reason, because we want to go somewhere, and our mind tends to think about where it wants to go and what it’s going to do there.  In mindful walking, we “pay attention on purpose” to the experience of walking itself.  

Arrange the room so that there is enough space for the group to walk in a circle or in lanes, and show the participants where you want them to walk.  Lead the group in your own words, using the following script as a guide:

“Stand up and relax your abdominal muscles.  Take several deep breaths, feeling your belly expand and contract with each breath.

Now begin to walk slowly.  Be aware of your feet and legs as your walk.  Notice what it feels like when one foot touches the floor, when your weight shifts to that foot, when the other foot lifts and the knee bends and the leg moves ahead and then that foot touches the floor.

Keep your gaze softly focused in front of you.  Don’t look at your feet or at what’s around you in the room or at other people.  If you do find your eyes wandering, return your attention to the sensations of walking.

When thoughts or feelings arise, notice them and then return your attention to the sensations of walking.”  

Allow time for the group to walk several times around the room.

Ask the group to share their experiences with the exercise.  If not brought out in the discussion, ask the following questions:
C	How did this experience differ from the way you usually walk?
C	Are there times during the day when you might be able to practice this type of walking (for example, when you walk between your car and your home at the end of the day)?
C	Do you think it would be possible to be more mindful when you are doing the brisk walking or equivalent activity you do to reach your DPP activity goal?  If so, do you think it would affect the amount of activity you do or your attitude toward it?  
C	What got in the way of paying attention to the process of walking?  What was it like to return your focus to the walking itself?

5.	Summarize the main points from this and previous sessions.  Assign home activity:
	C	Plan one time during the week when you can practice mindful eating (it needs to be a time when you can eat a meal alone, make it last for at least 30 minutes, and be away from other stimuli such as TV and radio).  Write that time on the cover of your Keeping Track booklet (check that participants have done so).  During the practice, eat with the hand you normally don’t use (the awkwardness may remind you to pay attention), and focus on the sights, smells, tastes, and textures of what you eat and drink.  Also, try to introduce some mindfulness into all of your eating during the week.
C	Plan to practice slow, mindful walking once during the coming week.  Write the days and time on the cover of your Keeping Track.  When practicing, walk very slowly.  Also, try to introduce some mindfulness into the brisk walking or other equivalent activity you do to reach the DPP activity goal.
C	Continue to self-monitor your stress and use mindfulness, body relaxation, body awareness, and breathing as ways to respond to stress rather than overeating or being sedentary (ie, to break the chain between stress and unhealthy eating/sedentary behavior).  Also remember that these and other relaxation techniques are important to practice regularly as ways to prevent stress.
C	Continue to keep in mind the Life Balance Pyramid.  Note any items on the pyramid that you practice.  Also notice any items or areas on the pyramid that you tend to neglect.

Encourage participants to discuss stress management with their Lifestyle Coaches throughout the remainder of the study and use their Coaches as a source of support in this area.